Information Collection

MUH Resident Baseline Survey - screening LA county

IC 204425 under ICR 201210-0920-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
MUH Resident Baseline Survey - screening LA county	Form
Resident Baseline Survey - screener - English Att 8A(e)_MUH Resident Baseline Survey_8 30 2012.doc	Form
Resident Baseline Survey - screener Spanish Att 8A(s)_MUH Resident Baseline Survey_8 30 2012.doc	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Resident Baseline Survey - screener - English	Att 8A(e)_MUH Resident Baseline Survey_8 30 2012.doc		No	No	Paper Only
Form	none	Resident Baseline Survey - screener Spanish	Att 8A(s)_MUH Resident Baseline Survey_8 30 2012.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 833

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	833	833
Annual IC Time Burden (Hours)	69	69
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.